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Minnesota Department of Public Safety
<br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION
<br /> 444 Cedar St., Suite 133, St. Paul, MN 55101-5133 ' ~ .....
<br /> (651) 296-6979 FAX (651)297-5259 ~Y(651)282-6555
<br /> WWW.DPS.STATE..~.US
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<br /> APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br /> No license will be approved or released until the $20 Retaiier iD C~rd :fe~ i~ rec~i~e~d:
<br />Workers compensation insurance company. Name ~e.n ~c ~ ~a ~ ~ c ~ ~ r ~ Policy ~ ~0 - O 50 6 [
<br />Licensee's MN Sales and Use Tax ID ~ ~ o ~ ~ ~ ~ 7 t To appO for a MN sates and use t~ ID ~, cal1(651) 296-6181
<br />Licensee's Federal Tax ID ~ ~/- O ~ ~ ¢1 0
<br />If a cnrporation, nn officer shall execute this application If a partnership, a partner shall execute this application.
<br />I.icensce Name (Individual, Corporation, Partnership, LLC) Social Securi~ ~ {Trade Name or DBA
<br />
<br />l.iccnsc Location (Street Address & Block No.) License Period Applicant's HomOPhone 0
<br />r:itv CounW { State Zip Code
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<br />Name of Store Manitgcr Business Phone Number DOB (Individual Applicant)
<br />
<br />If a cm-poralion or LLC state name, date of birth, Social Security ~ address, title, and shares held By each officer. Ifa partnership, state
<br />names, address and dnte of birth of each partner.
<br />
<br />Parmcr Officer (First, middle, last) DOB SS# Title
<br />l>allncr Of'liter (First, middle, last) DOB SS# Fitle
<br />Pmlncr Officer (First, middle, last) DOB SS# title
<br />l'armcr ()lticcr (First, middle, last) DOB SS# Title
<br />
<br />Shares
<br />Shares
<br />Shares
<br />Shares
<br />
<br />Address, City, State, Zip Code
<br />
<br />Address, City, State, Zip Code
<br />Address, City, State, Zip Code
<br />Address, City, State, Zip Code
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<br />Ir'at corporation, date of incorporation i ~1.- 1%-- ~' ~ , state incorporated in ~', o,.e,, ~ x o'-t-c-- , amount paid in
<br />capital . If a subsidiary of any other corporation, so state and give purpOse of
<br />corporathm · - . If incorporated under the laws of another state, is corporation
<br />authorized to do business in the state of Minnesota? [] Yes
<br />
<br />Dcscribc premises to which license applies; such a~ (first floor, second floor, basement, etc.) or if entire building, so state.
<br />
<br />[s cstab iMm~cnt iocatcd near any state amvers~ty, state hospital, trmnmg school, reformatory or prison? [JYes ~o If yes state
<br />approxmmte distance.
<br />
<br />,4.
<br />
<br />Namcandaddrcssofbuildingowner: Rtkrn ac~.vxc' e L/.--Q__ : O_..[O' . ~', ~'5'O 6 e e J~ct~ \d-o._F'--J _
<br />
<br />Has own& of building any connection, directly or indirectly, vCith applicant? [] Yes [] No
<br />ls applicant o,' any of the associates in this application, a member of the governing body of the municipality in which this license is
<br />to hc issued? :l Yes *~o If yes, in what capacity?
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<br />State whclhcr any person other than applicants has any right, title or interest in the furniture, fixtures or equipment for which license
<br />
<br />applied ;md if so, give name and details.
<br />
<br />1 la~y aplflicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota?
<br />/Yes Nolt'ycs, givenameandaddressofestablishment. .-5'e -<__ ,~--'t~'~ ~_ L ~ 4_ ~,'; ~. 'P-
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